<html>
	<head>
		<title>Sample Form</title>
		<style type="text/css">
			.left
			{
				text-align: right;
			}
		</style>
	</head>
	
	<body>
		<form>
			<table cellpadding="5" cellspacing="0" border="1">
				<tr>
					<td class="left"><b>Last Name</b></td>
					<td colspan="3"><input type="text" name="lastName" size="55"/></td>
				</tr>
				<tr>
					<td class="left"><b>First Name</b></td>
					<td colspan="3"><input type="text" name="firstName" size="55"/></td>
				</tr>
				<tr>
					<td class="left"><b>Address</b></td>
					<td colspan="3"><textarea name="address" style="width: 90%"></textarea></td>
				</tr>
				<tr>
					<td class="left"><b>City</b></td>
					<td><input type="text" name="city" size="35" />
					<td><b>State</b></td>
					<td><input type="text" name="state" size="10"</td>
				</tr>
				<tr>
					<td class="left"><b>Zip/Postal Code</b></td>
					<td colspan="3"><input type="text" name="postalCode" size="8"/></td>
				</tr>
				<tr>
					<td class="left"><b>Country</b></td>
					<td colspan="3">
						<select name="country">
							<option>Bulgaria</option>
							<option>United States of America</option>
							<option>United Kingdom</option>
						</select>
					</td>
				</tr>
				<tr>
					<td class="left"><b>Phone (country code,<br/>area code, number</b></td>
					<td colspan="3">(+<input type="text" name="countryCode" size="6"/>)
						<input type="text" name="areaCode" size="6"/> 
						- <input type="text" name="number" size="15"/>
				</tr>
				<tr>
					<td class="left"><b>E-mail</b></td>
					<td colspan="3"><input type="text" name="email" size="45"/>
				</tr>
				<tr>
					<td class="left"><b>Birth date</b></td>
					<td colspan="3">Month <input type="text" name="month" size="10"/>
					Day<input type="text" name="day" size="3"/> Year(4 digit)
					   <input type="text" name="day" size="5"/></td>
				</tr>
				<tr>
					<td class="left"><b>Gender</b></td>
					<td colspan="3">
						<select name="gender">
							<option>Male</option>
							<option>Female</option>
						</select>
					</td>
				</tr>
				<tr>
					<td class="left"><b>Starting date</b></td>
					<td colspan="3">
						<input type="radio" name="startDate" value="spring2006">Spring 2006</input>
						<input type="radio" name="startDate" value="summer2006">Summer 2006</input>
					</td>
				</tr>
				<tr>
					<td class="left"><b>Comments/Questions</b></td>
					<td colspan="3"><textarea name="comments" style="width: 90%; height: 90px"></textarea></td>
				</tr>
				<tr>
					<td colspan="4" style="background-color: #c2f1f3;text-align: center">
						<input type="button" name="submit" value="Submit this form"/>
						<input type="button" name="clear" value="Clear this form"/>
					</td>
				</tr>
			</table>
		</form>
	</body>
</html>